Obsessive-Compulsive Disorder:

Diagnosis and Management

JILL N. FENSKE, MD, and KETTI PETERSEN, MD, University of Michigan Medical School, Ann Arbor, Michigan

Obsessive-compulsive disorder (OCD) is a chronic illness that can cause marked distress and disability. It is a complex
disorder with a variety of manifestations and symptom dimensions, some of which are underrecognized. Early recogni-
tion and treatment with OCD-specific therapies may improve outcomes, but there is often a delay in diagnosis. Patients
can experience significant improvement with treatment, and some may achieve remission. Recommended first-line
therapies are cognitive behavior therapy, specifically exposure and response prevention, and/or a selective serotonin
reuptake inhibitor (SSRI). Patients with OCD require higher SSRI dosages than for other indications, and the treatment
response time is typically longer. When effective, long-term treatment with an SSRI is a reasonable option to prevent
relapse. Patients with severe symptoms or lack of response to first-line therapies should be referred to a psychiatrist.
There are a variety of options for treatment-resistant OCD, including clomipramine or augmenting an SSRI with an
atypical antipsychotic. Patients with OCD should be closely monitored for psychiatric comorbidities and suicidal ide-
ation. (Am Fam Physician. 2015;92(10):896-903. Copyright © 2015 American Academy of Family Physicians.)

O
CME This clinical content
conforms to AAFP criteria
for continuing medical
education (CME). See
CME Quiz Questions on
page 869.
Author disclosure: No rel-
evant financial affiliations.
Patient information:
▲
bsessive-compulsive disorder
(OCD) is a neuropsychiatric dis-
order characterized by recurrent
distressing thoughts and repeti-
tive behaviors or mental rituals performed to
reduce anxiety. Symptoms are often accom-
panied by feelings of shame and secrecy. In
addition, health care professionals do not
severe symptoms seek help. The mean age of
onset is 19.5 years, and it is rare for new cases
of OCD to develop after the early 30s.2 A sub-
set of patients, mostly males, have an early
onset (before 10 years of age). The lifetime risk
of developing OCD is higher in females, who
typically develop the disorder in adolescence.2

A handout on this topic is always recognize the diverse manifestations Course of Illness
available at http://family​ of OCD. These factors often lead to a long OCD has a substantial effect on quality of
doctor.org/family​doctor/
delay in diagnosis. The average time it takes life and level of functioning.3 It is often a
en/diseases-conditions/
obsessive-compulsive- to receive treatment after meeting diagnostic chronic disorder (60% to 70% of cases) and
disorder.html. criteria for OCD is 11 years.1 Primary care is likely to persist if not treated effectively.1,4
physicians can play a crucial role in reducing Significant improvement or remission is
the burden of OCD through early detection possible when evidence-based therapies are
and treatment. applied. Patients with a later age of onset,
shorter duration of symptoms, good insight,
Epidemiology and response to initial treatment have an
The lifetime prevalence of OCD is 2.3%,2 increased likelihood of remission.5-7 Early
although this may be an underrepresentation and aggressive treatment of OCD, with a goal
because often only patients with moderate to of remission, is important for a positive out-
come.5 Therefore, it is critical that primary
care physicians are equipped to diagnose
WHAT IS NEW ON THIS TOPIC: OCD and treat patients with OCD appropriately.
Insufficient treatment and a lack of OCD-
In the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., OCD specific resources are important problems
is recognized as a disorder distinct from anxiety.
in the management of this disorder. In one
Incorporating motivational interviewing may increase engagement with
study population, only 30.9% of patients
cognitive behavior therapy for OCD and improve its effectiveness.
with severe symptoms and 2.9% of patients
OCD = obsessive-compulsive disorder. with moderately severe symptoms received
treatment specific for OCD.2

896  American
Downloaded Family
from the Physician
American www.aafp.org/afp
Family Physician website at www.aafp.org/afp. American Academy
Copyright © 2015 Volume 92, Number
of Family 10 ForNovember
Physicians. the private, 15,
◆ 2015
noncom-
mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
 Obsessive-Compulsive Disorder
Table 1. Common Symptoms in Patients with Obsessive-Compulsive Disorder

Obsession Examples Associated compulsive behaviors

Aggressive Fear of harming others, recurrent violent images Monitoring the news for reports of violent crimes,
asking for reassurance about being a good person

Contamination Fear of being contaminated or contaminating others; Washing or cleaning rituals

fear of being contaminated by germs, infections, or
environmental factors; fear of being contaminated
by bad or immoral persons

Pathologic doubt, Recurrent worries about doing things incorrectly Checking excessively, performing actions in a
completeness or incompletely, thereby negatively affecting the particular order
patient or others

Religious Thoughts about being immoral and eternal damnation Asking forgiveness, praying, reassurance seeking

Self-control Fear of making inappropriate comments in public Avoiding being around others

Sexual Recurrent thoughts about being a pedophile or Avoiding situations that trigger the thoughts,
sexually deviant; recurrent thoughts about acting performing mental rituals to counteract the
sexually inappropriate toward others thoughts

Superstition Fears of certain “bad” numbers or colors Counting excessively

Symmetry and Recurrent thoughts of needing to do things in a Ordering and arranging

exactness balanced or exact fashion

Adapted with permission from Grant JE. Clinical practice: obsessive-compulsive disorder. N Engl J Med. 2014;371(7):649.

Pathogenesis In the Diagnostic and Statistical Manual of Mental Dis-

The pathogenesis of OCD is a complex interplay between
neurobiology, genetics, and environmental influences.
Historically, dysfunction in the serotonin system was
postulated to be the main factor in OCD pathogenesis,
given the selective response to serotonergic medication.
More recent research has also demonstrated the role of
glutamate, dopamine, and possibly other neurochemi-
cals.8 A proposed model for OCD suggests that genetic
vulnerability to environmental stressors may result in
modification of gene expression within neurotransmit-
ter systems. This, in turn, results in changes to brain cir-
cuitry and function.8
Diagnosis
Obsessions are recurrent intrusive thoughts or images
that cause marked distress. The thoughts are unwanted
and inconsistent with the individual’s sense of self (ego-
dystonic), and great effort is made to resist or suppress
them. They can involve contamination; repeated doubts;
or taboo thoughts of a sexual, religious, or aggressive
nature. Compulsions are repetitive behaviors or mental
rituals performed to counteract the anxiety caused by
obsessions. Individuals feel strongly compelled to com-
plete these actions, and the behaviors become automatic
over time. They can include handwashing, checking,
ordering, praying, counting, and seeking reassurance.
Common obsessions and compulsions are included
in Table 1.9
orders, 5th ed., OCD is recognized as a disorder distinct
from anxiety (Table 2) and is now grouped with several
other disorders with common features, often referred to as
obsessive-compulsive–related disorders (Table 3).10 OCD
is a complex, heterogeneous disorder, and some presenta-
tions are underrecognized. For example, taboo thoughts
may be attributed to other causes or may not appear to be
associated with overt compulsions. Even when compul-
sions are not easily observable, patients with OCD usually
have mental rituals. Patients are often reluctant to report
symptoms of OCD for a variety of reasons, including
embarrassment, stigma, and the fear of what the obsession
might mean or the consequences of revealing it.11
Physicians should consider the possibility of OCD in
patients with general complaints of anxiety or depres-
sion. Patients may offer clues by alluding to intrusive
thoughts or repetitive behaviors. Avoidance of particular
locations or objects, excessive concerns about illness or
injury, and repetitive reassurance-seeking behavior are
also common. It is important to note that obsessive-
compulsive personality disorder is a separate diagnos-
tic entity that is not characterized by intrusive thoughts
or repetitive behaviors. Rather, it is a pervasive pattern
of behaviors emphasizing organization, perfectionism,
and a sense of control.10 If true OCD is suspected, the
use of a few simple screening questions can be helpful
(Table 4).12 Standardized diagnostic tools are available,
but most are not practical for use in primary care. Two

November 15, 2015 ◆ Volume 92, Number 10 www.aafp.org/afp American Family Physician 897
Obsessive-Compulsive Disorder
Table 2. DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as
intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other
thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently)
that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event
or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to
neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress
or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized
anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with
possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation
[skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders;
preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an
illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control,
and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in
schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not
true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.

Reprinted with permission from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington,
DC: American Psychiatric Association; 2013:237.

commonly used patient self-report inventories are the
Obsessive-Compulsive Inventory–Revised13 (http://
www.cale​black.com/psy​5960​_files/OCI-R.pdf) and the
Florida Obsessive-Compulsive Inventory 14 (http://www.
ocdscales.org/index.php?page=scales).
OCD is often misdiagnosed as other disorders
(Table 5),9,10 although OCD is a common comorbidity
for many of these conditions, and the possibility of more
than one diagnosis should be considered. Psychiatric
referral is indicated if there is diagnostic uncertainty.
Comorbidities
Patients with OCD should be monitored for psychiat-
ric comorbidities and suicide risk.15-17 In their lifetime,
90% of patients with OCD meet criteria for at least
one other psychiatric diagnosis.2 The most common
comorbid diagnoses are anxiety disorders (75.8%),
including panic disorder, social phobia, specific pho-
bias, and posttraumatic stress disorder. Other common
comorbidities include mood disorders (63.3%), particu-
larly major depressive disorder (40.7%); impulse control
disorders (55.9%); and substance use disorders (38.6%).2
The risk of suicide in persons with OCD is high. In one
community survey, 63% of persons with OCD had
experienced suicidal thoughts, and 26% had attempted
suicide.18 Comorbidity with depression, posttraumatic
stress disorder, substance abuse, or impulse control dis-
orders increases the risk of suicidal behavior.15,16
Treatment
Once OCD is diagnosed, it is important to provide the
patient with information and support. Patients and
family members should be educated about the chronic
nature of OCD and the importance of self-management
skills. Evidence-based medical and behavior therapies
can reduce the severity and frequency of obsessions and
compulsions, and can induce remission in some patients.
Because it may take weeks to months for these therapies

898  American Family Physician www.aafp.org/afp Volume 92, Number 10 ◆ November 15, 2015
 Obsessive-Compulsive Disorder
Table 3. Obsessive-Compulsive–Related Disorders

Disorder Diagnostic criteria Clinical features Preferred treatment

Body dysmorphic Preoccupation with perceived defects
disorder or flaws in physical appearance
that leads to repetitive behaviors
or mental acts in response to the
apparent concerns
Poor insight
Seeks care from dermatologists
and cosmetic surgeons to address
perceived defects
Symptom onset during adolescence
Waxing and waning course
Cognitive behavior therapy
(exposure and response
prevention)
Some evidence for SSRIs

Excoriation Recurrent skin picking resulting in skin More common in females Habit reversal therapy
(skin-picking) lesions Symptom onset at the beginning Limited studies
disorder Repeated attempts to decrease or of puberty evaluating response to
stop skin picking pharmacotherapy

Hoarding Persistent difficulty discarding or
disorder parting with possessions because of
strong urges to save items and/or
distress with discarding items
Accumulation of possessions to
a degree that the space where
possessions accumulate cannot be
used as intended
75% of patients with hoarding Behavior therapy targeted
disorder have comorbid mood or toward removal of
anxiety disorders hoarded items and
The hoarding causes significant reduction in accumulation
distress or impairment in function of new items
Symptom onset between 11 and 15 No data to support
years of age pharmacotherapy
Symptoms or hoarding behaviors
progressively worsen

Trichotillomania Recurrent pulling of hair from any part More common in females Habit reversal therapy
(hair-pulling of the body resulting in hair loss Symptom onset at the beginning Mixed to poor response to
disorder) Repeated attempts to decrease or of puberty SSRIs
stop hair pulling

SSRI = selective serotonin reuptake inhibitor.

Information from reference 10.

to become effective, physicians should inform patients
about this delay in treatment response and encourage
adherence during the early phase of treatment.
It is helpful to quantify the severity of symptoms and
impairment before and during treatment. This may
be done using standardized rating scales, or by patient
Table 4. Initial Screening Questions for
Obsessive-Compulsive Disorder
Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you
would like to get rid of but cannot?
Do your daily activities take a long time to finish?
Are you concerned about putting things in a special order,
or are you very upset by mess?
Do these problems trouble you?
NOTE: If a person answers “yes” to any of these questions and the
symptom causes distress, a diagnostic interview or patient symptom
inventory should be administered.
Information from reference 12.
report of the time expended on obsessions or compul-
sions and the level of distress they cause. The Yale-
Brown Obsessive-Compulsive Scale—second edition
(Y-BOCS-II) is a reliable tool for measuring OCD symp-
tom severity 19 and is available at http://ericwexlermd.
com/MB_PDFs/OCD/YBOCSII.pdf.
Patients should be assessed for suicide risk and pres-
ence of comorbidities throughout the course of their
illness. Treatment is indicated when OCD symptoms
impair the patient’s functioning or cause significant dis-
tress. Reasonable treatment goals are spending less than
one hour per day on obsessive-compulsive behaviors and
achieving minimal interference with daily tasks.17 Psy-
chiatric consultation is recommended for patients with
severe OCD, as measured by the Y-BOCS-II. Figure 1 is
an algorithm for the treatment of OCD.17,20-25
PSYCHOLOGICAL TREATMENTS
Cognitive behavior therapy (CBT), specifically expo-
sure and response prevention, is the most effective
psychotherapy method for treating OCD.17,20,21 Patients
are exposed to anxiety-provoking stimuli, and learn to
not perform compulsive behaviors in response. Ideally,
CBT should be administered by a trained health care

November 15, 2015 ◆ Volume 92, Number 10 www.aafp.org/afp American Family Physician 899
Obsessive-Compulsive Disorder
Table 5. Conditions That May Be Misdiagnosed as OCD

Misdiagnosis Distinctions

ADHD Young persons with ADHD may procrastinate and have problems with attention and focus; persons with OCD
may appear to have ADHD because they have a need to do things “just right” or in a “complete” fashion and
therefore may not complete tasks; it is important to determine whether mental rituals or obsessive thoughts
interfere with focus and attention

Anxiety Anxiety is characterized by worry, which often mimics obsessive thinking; anxiety usually focuses on real-life
disorder problems (e.g., finances, health, loved ones) without the irrational quality of OCD

Autism Persons with autism spectrum disorders exhibit persistent deficits in social interactions and may engage
spectrum in repetitive behaviors perceived as natural and reasonable; OCD can lead to social isolation, but social
disorders communication skills are usually preserved; persons with OCD usually view their compulsive repetitive behaviors
as excessive and unreasonable

Depression Persons with depression often ruminate, which may be mistaken for obsession; however, these ruminations are of
a depressed theme (e.g., guilt due to inadequacies or negative self-assessment)

Psychotic Psychosis is often characterized by delusional beliefs; OCD thoughts may also be irrational (e.g., fear of
disorder contracting human immunodeficiency virus from doorknobs); however, unlike with psychosis, persons with OCD
can usually recognize that their thoughts are irrational but cannot control them

Tourette In Tourette syndrome, motor or vocal tics are generally involuntary; repetitive behaviors in OCD result from a cognitive
syndrome source (e.g., an obsessive desire for symmetry) and the need to perform an action until it is done “just right”

ADHD = attention-deficit/hyperactivity disorder; OCD = obsessive-compulsive disorder.

Adapted with permission from Grant JE. Clinical practice: obsessive-compulsive disorder. N Engl J Med. 2014;371(7):650, with additional information
from reference 10.

professional in an individual or group format, although
studies have suggested that self-directed exposure and
response prevention combined with motivational inter-
viewing may be effective.26,27 Incorporating motivational
interviewing may increase engagement with therapy and
improve its effectiveness.28 There is no evidence for the
use of psychodynamic psychotherapy or “talk therapy”
to treat OCD.
PHARMACOTHERAPY
OCD has a highly selective response to serotonergic
medications. Clomipramine (Anafranil), a tricyclic
antidepressant with a strong serotonergic effect, was
previously the first-line pharmacologic treatment for
OCD. However, because of concerns about its safety
and adverse effects, selective serotonin reuptake inhibi-
tors (SSRIs) are now preferred for initial therapy.17,21 A
Cochrane review confirmed the effectiveness of SSRIs
for the treatment of OCD (absolute risk reduction = 8%
to 17%; number needed to treat = 6 to 12).29 Fluoxetine
(Prozac), fluvoxamine, paroxetine (Paxil), and sertraline
(Zoloft) have been approved by the U.S. Food and Drug
Administration (FDA) for the treatment of OCD. Citalo-
pram (Celexa) and escitalopram (Lexapro) are also com-
monly used, but in 2011, the FDA began recommending
dose limitations for citalopram because of concerns
about QT prolongation.30 There is insufficient evidence
to show that one SSRI is superior,22 and the choice of SSRI
should be individualized, taking into account potential
drug interactions and tolerability.
To achieve optimal response, patients with OCD
require a higher dosage of an SSRI compared with other
indications.17,31 The dosage should be increased over
four to six weeks until the maximal dosage is achieved
(Table 6).30,32 Higher-than-usual maximal dosages are
sometimes used, with careful monitoring for adverse
effects such as serotonin syndrome. The trial of therapy
should continue for eight to 12 weeks, with at least four
to six weeks at the maximal tolerable dosage.17 It usu-
ally takes at least four to six weeks for patients to note
any significant improvement in symptoms; it may take
10 weeks or longer for some.
If medical therapy is successful, it should be continued
for at least one to two years, if not indefinitely.17,22 Relapse
prevention with continuous SSRI therapy is a reasonable
treatment goal.33 If the patient chooses to discontinue
pharmacotherapy, the dosage should be gradually tapered
over several months, and the original dosage resumed if
symptoms worsen. The response to psychological treat-
ments may last longer than the response to medications.34
Periodic “booster” sessions of exposure and response
prevention are recommended to lower the risk of relapse
when psychological therapy is discontinued.17
If an adequate trial of SSRI or psychological therapy
does not result in a satisfactory response, combined treat-
ment is an option.35,36 If the patient prefers to continue

900  American Family Physician www.aafp.org/afp Volume 92, Number 10 ◆ November 15, 2015
 Obsessive-Compulsive Disorder
Treatment of Obsessive-Compulsive Disorder
Assess severity of OCD

Because clomipramine can cause anticholin-

ergic adverse effects, and rarely arrhythmia
Mild to moderate Severe
or seizures, it should be started at a low dos-
age (25 mg per day) with gradual titration to
Option Option minimize adverse reactions. Addition of an
atypical antipsychotic is effective for some
CBT*
patients with inadequate response to SSRI
therapy.17,25,37 There is conflicting evidence
regarding which atypical antipsychotic agent
Initiate
Satisfactory Unsatisfactory psychiatric is most effective, and the usefulness of these
improvement improvement referral medications is offset by a higher risk of
adverse effects than SSRI monotherapy.25
Complete initial SSRI with or without CBT*
There are a variety of other options for
treatment course patients with treatment-resistant OCD, but
Consider periodic the evidence for most therapies is limited.
“booster” sessions Some studies support the effectiveness of
of CBT*
serotonin-norepinephrine reuptake inhibi-
tors or mirtazapine (Remeron) for OCD.38-40
Other medications under investigation
Satisfactory Unsatisfactory improvement
include glutamatergic agents, stimulants,
improvement
pindolol, ondansetron (Zofran), acetylcys-
Switch to a new SSRI; add CBT if not already initiated teine, and anticonvulsants.23-25 Deep brain
stimulation has had promising results for
severe treatment-resistant OCD, but it has
been studied in only a small number of
Satisfactory Unsatisfactory improvement patients. This treatment is used as a last
improvement
resort and has received limited FDA approval
Initiate psychiatric referral for treatment resistance under the humanitarian device exemption.41
Continue medication for at Therapy options include:
least 1 to 2 years (indefinite
Switching to clomipramine (Anafranil) Special Populations
treatment is reasonable)
Augmenting the SSRI with an antipsychotic PREGNANCY AND POSTPARTUM
Consider periodic “booster”
sessions of CBT* Combining an SSRI with clomipramine Women who are pregnant or in the postpar-
Going beyond the higher-than-usual maximal tum period are 1.5 to 2 times more likely to
dose of the SSRI, with careful monitoring for
adverse effects, such as serotonin syndrome
experience OCD compared with the general
Using an alternative agent: mirtazapine female population.42 Women who had OCD
(Remeron) or an SNRI† before pregnancy may have worsening OCD
Trying investigational treatments symptoms and are at higher risk of postpar-
tum depression.42-44 Postpartum OCD may
*—Exposure and response prevention. manifest as intrusive thoughts of harming
†—Limited evidence.
the infant; however, these women are not at
increased risk of injuring their infants.42 CBT
Figure 1. Algorithm for the treatment of OCD. (CBT= cognitive behav- is recommended as first-line treatment for
ior therapy; OCD = obsessive-compulsive disorder; SNRI = serotonin- OCD during pregnancy and the postpartum
norepinephrine reuptake inhibitor; SSRI= selective serotonin reuptake period. An individual risk-benefit analysis
inhibitor.) should be discussed when considering SSRI
Information from references 17, and 20 through 25. therapy during pregnancy and lactation.44

with medical therapy alone, a trial of a different SSRI is
warranted.17 If there is no response to trials of at least
two SSRIs, the patient should be referred to a psychia-
trist. Clomipramine is an option in these patients.17
CHILDREN
The prevalence of childhood OCD is 1% to 2% in
the United States, and 50% of these children have
comorbid psychiatric conditions. CBT with exposure

November 15, 2015 ◆ Volume 92, Number 10 www.aafp.org/afp American Family Physician 901
Obsessive-Compulsive Disorder
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Patients with OCD should be monitored for psychiatric comorbidities and suicide risk. C 15-17
Cognitive behavior therapy, specifically exposure and response prevention, is the most effective A 17, 20, 21
psychotherapy method for treating OCD.
SSRIs are recommended as first-line pharmacologic therapy for OCD. A 17, 21, 29
A trial of SSRI therapy should continue for 8 to 12 weeks, with at least 4 to 6 weeks at the maximal C 17
tolerable dosage.
Indefinite SSRI therapy should be considered to prevent OCD relapse. At a minimum, SSRIs should be C 17, 22
continued for 1 to 2 years before attempting to discontinue.
Augmenting SSRI therapy with an atypical antipsychotic is effective in some patients with OCD who B 17, 25, 37
have inadequate response to SSRI therapy.

OCD = obsessive-compulsive disorder; SSRI = selective serotonin reuptake inhibitor.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.

and response prevention is the preferred initial treat- neuropsychiatric disorders associated with streptococ-
ment for mild to moderate cases.45 Family involvement cal infection (PANDAS). The term PANDAS is falling
is important for successful outcomes.45,46 Treatment with out of favor because of controversy regarding the etio-
SSRIs, in addition to CBT, is indicated for patients with logic role of group A streptococcal infection. A pro-
severe symptoms or comorbid psychiatric conditions posed new label for this diagnosis is childhood acute
limiting CBT participation. CBT with or without medi- neuropsychiatric symptoms (CANS).48 CANS has many
cation is superior to medication alone for treatment of proposed etiologic factors, including infectious, toxic,
childhood OCD.47 and metabolic causes. There are currently no standard
Abrupt onset of obsessive-compulsive symptoms in guidelines for the management of CANS, but a compre-
children may raise concern for pediatric autoimmune hensive evaluation is recommended, and empiric antibi-
otics are not indicated.48
Data Sources: A PubMed search was completed using
Table 6. SSRIs Commonly Used to Treat Obsessive- the key term obsessive-compulsive disorder, as well as
Compulsive Disorder individual components of the term. The search included
meta-analyses, randomized controlled trials, and practice
guidelines within the previous five years. Also searched
Dosage (mg per day) were the Cochrane database, Database of Abstracts of
Reviews of Effects, BMJ Clinical Evidence, National Guide-
SSRI Starting Target Maximal Cost* line Clearinghouse database, and Essential Evidence Plus.
We performed multiple targeted searches in PubMed and
Citalopram (Celexa) 20 40† 40† $4 ($200)
of reference lists of previously retrieved articles to further
Escitalopram (Lexapro) 10 20 40 $13 ($240) research specific topics, such as course of illness, patho-
Fluoxetine (Prozac)‡ 20 40 to 60 80 $4 ($305) genesis, suicidality, and special populations. Search dates:
Fluvoxamine‡ 50 200 300 $17 (not October to December 2014, and September 2015.
available) NOTE:This review updates a previous article on this topic
Paroxetine (Paxil)‡ 20 40 to 60 60 $4 ($160) by Fenske and Schwenk.49
Sertraline (Zoloft)‡ 50 200 200 $10 ($215)
The Authors
FDA = U.S. Food and Drug Administration; SSRI = selective serotonin reuptake
inhibitor. JILL N. FENSKE, MD, is a clinical assistant professor in the
Department of Family Medicine at the University of Michi-
*—Estimated retail price of one month’s supply (starting dosage) based on informa-
gan Medical School, Ann Arbor.
tion obtained at http://www.goodrx.com (accessed August 26, 2015). Generic price
listed first, brand price listed in parentheses. KETTI PETERSEN, MD, is a clinical lecturer in the Depart-
†—The FDA recommends against citalopram dosages > 40 mg per day (or > 20 mg ment of Family Medicine at the University of Michigan
per day in patients older than 60 years or with hepatic impairment) because of con- Medical School.
cern for QT prolongation. If a higher dosage is necessary, the patient should be moni-
tored using electrocardiography and electrolyte measurements.30 Address correspondence to Jill N. Fenske, MD, Dept. of
‡—FDA approved for the treatment of obsessive-compulsive disorder. Family Medicine, University of Michigan, 1150 W. Medi-
cal Center Dr., M7300 Med Sci I, SPC 5625, Ann Arbor,
Information from references 30 and 32. MI 48109-5625 (e-mail: jnfenske@med.umich.edu).
Reprints are not available from the authors.

902  American Family Physician www.aafp.org/afp Volume 92, Number 10 ◆ November 15, 2015

REFERENCES
1. Pinto A, Mancebo MC, Eisen JL, et al. The Brown Longitudinal Obsessive
Compulsive Study. J Clin Psychiatry. 2006;67(5):703-711.
2. Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of
obsessive-compulsive disorder in the National Comorbidity Survey Rep-
lication. Mol Psychiatry. 2010;15(1):53-63.
3. Huppert JD, Simpson HB, Nissenson KJ, Liebowitz MR, Foa EB. Qual-
ity of life and functional impairment in obsessive-compulsive disorder.
Depress Anxiety. 2009;26(1):39-45.
4. Visser HA, van Oppen P, van Megen HJ, et al. Obsessive-compulsive
disorder. J Affect Disord. 2014;152-154:169-174.
5. Eisen JL, Sibrava NJ, Boisseau CL, et al. Five-year course of obsessive-
compulsive disorder. J Clin Psychiatry. 2013;74(3):233-239.
6. Jakubovski E, Diniz JB, Valerio C, et al. Clinical predictors of long-term
outcome in obsessive-compulsive disorder. Depress Anxiety. 2013;30
(8):763-772.
7. Cherian AV, Math SB, Kandavel T, Reddy YC. A 5-year prospective follow-up
study of patients with obsessive-compulsive disorder treated with sero-
tonin reuptake inhibitors. J Affect Disord. 2014;152-154:387-394.
8. Pauls DL, Abramovitch A, Rauch SL, Geller DA. Obsessive-compulsive
disorder. Nat Rev Neurosci. 2014;15(6):410-424.
9. Grant JE. Clinical practice: obsessive-compulsive disorder. N Engl J Med.
2014;371(7):646-653.
10. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washing-
ton, DC: American Psychiatric Association; 2013.
11. Fineberg NA, et al. Clinical screening for obsessive-compulsive and
related disorders. Isr J Psychiatry Relat Sci. 2008;45(3):151-163.
12. Obsessive-Compulsive Disorder. London, UK: NICE; 2005.
13. Foa EB, Huppert JD, Leiberg S, et al. The Obsessive-Compulsive Inven-
tory. Psychol Assess. 2002;14(4):485-496.
14. Storch EA, et al. Florida Obsessive-Compulsive Inventory [published correc-
tion appears in J Clin Psychol. 2007;63(12):1265]. J Clin Psychol. 2007;63(9):
851-859.
15. Torres AR, Ramos-Cerqueira AT, Ferrão YA, et al. Suicidality in obsessive-
compulsive disorder. J Clin Psychiatry. 2011;72(1):17-26.
16. Kamath P, Reddy YC, Kandavel T. Suicidal behavior in obsessive-
compulsive disorder. J Clin Psychiatry. 2007;68(11):1741-1750.
17. Koran LM, et al. Practice guideline for the treatment of patients with
obsessive-compulsive disorder. Am J Psychiatry. 2007;164(7 suppl):5-53.
18. Torres AR, Prince MJ, Bebbington PE, et al. Obsessive-compulsive disor-
der. Am J Psychiatry. 2006;163(11):1978-1985.
19. Storch EA, et al. Development and psychometric evaluation of the Yale-
Brown Obsessive-Compulsive Scale. Psychol Assess. 2010;22(2):223-232.
20. Rosa-Alcázar AI, et al. Psychological treatment of obsessive-compulsive
disorder. Clin Psychol Rev. 2008;28(8):1310-1325.
21. Canadian Psychiatric Association. Clinical practice guidelines. Manage-
ment of anxiety disorders [published correction appears in Can J Psy-
chiatry. 2006;51(10):623]. Can J Psychiatry. 2006;51(8 suppl 2):9S-91S.
22. Fineberg NA, et al. Evidence-based pharmacotherapy of obsessive-com-
pulsive disorder. Int J Neuropsychopharmacol. 2012;15(8):1173-1191.
23. Zohar J, ed. Obsessive-Compulsive Disorder: Current Science and Clini-
cal Practice. Hoboken, NJ: Wiley-Blackwell; 2012.
24. Obsessive-compulsive disorder. https://www.nice.org.uk/guidance/
cg31/evidence/cg31-obsessive-compulsive-disorder-ocd-and-body-
dysmorphic-disorder-bdd-evidence-update2. Accessed August 27, 2015.
25. Koran LM, Simpson HB. Guideline watch (March 2013): practice
guideline for the treatment of patients with obsessive-compulsive
disorder. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_
guidelines/guidelines/ocd-watch.pdf. Accessed August 27, 2015.
26. Tolin DF, et al. Stepped care versus standard cognitive-behavioral therapy
for obsessive-compulsive disorder. Depress Anxiety. 2011;28(4):314-323.
November 15, 2015 ◆ Volume 92, Number 10 www.aafp.org/afp
Obsessive-Compulsive Disorder
27. Jónsson H, Hougaard E, Bennedsen BE. Randomized comparative study
of group versus individual cognitive behavioural therapy for obsessive
compulsive disorder. Acta Psychiatr Scand. 2011;123(5):387-397.
28. Meyer E, Souza F, Heldt E, et al. A randomized clinical trial to examine
enhancing cognitive-behavioral group therapy for obsessive-compulsive
disorder with motivational interviewing and thought mapping. Behav
Cogn Psychother. 2010;38(3):319-336.
29. Soomro GM, Altman D, Rajagopal S, Oakley-Browne M. Selective sero-
tonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compul-
sive disorder (OCD). Cochrane Database Syst Rev. 2008;(1):CD001765.
30. U.S. Food and Drug Administration. Revised recommendations for Cel-
exa (citalopram hydrobromide) related to a potential risk of abnormal
heart rhythms with high doses. http://www.fda.gov/drugs/drugsafety/
ucm297391.htm. Accessed December 10, 2014.
31. Bloch MH, et al. Meta-analysis of the dose-response relationship of SSRI
in obsessive-compulsive disorder. Mol Psychiatry. 2010;15(8):850-855.
32. Micromedex 2.0. New York, NY: Thomson Reuters; 2015.
33. Fineberg NA, Pampaloni I, Pallanti S, Ipser J, Stein DJ. Sustained response
versus relapse. Int Clin Psychopharmacol. 2007;22(6):313-322.
34. Whittal ML, et al. Group and individual treatment of obsessive-
compulsive disorder using cognitive therapy and exposure plus response
prevention. J Consult Clin Psychol. 2008;76(6):1003-1014.
35. Foa EB, et al. Randomized, placebo-controlled trial of exposure and ritual
prevention, clomipramine, and their combination in the treatment of
obsessive-compulsive disorder. Am J Psychiatry. 2005;162(1):151-161.
36. Simpson HB, Huppert JD, Petkova E, et al. Response versus remission in
obsessive-compulsive disorder. J Clin Psychiatry. 2006;67(2):269-276.
37. Komossa K, et al. Second-generation antipsychotics for obsessive com-
pulsive disorder. Cochrane Database Syst Rev. 2010;(12):CD008141.
38. Denys D, van der Wee N, van Megen HJ, Westenberg HG. A double
blind comparison of venlafaxine and paroxetine in obsessive-compulsive
disorder. J Clin Psychopharmacol. 2003;23(6):568-575.
39. Dell’osso B, Mundo E, Marazziti D, Altamura AC. Switching from
serotonin reuptake inhibitors to duloxetine in patients with resis-
tant obsessive compulsive disorder. J Psychopharmacol. 2008;
22(2):210-213.
4 0. Koran LM, Gamel NN, Choung HW, et al. Mirtazapine for obsessive-
compulsive disorder. J Clin Psychiatry. 2005;66(4):515-520.
41. Goodman WK, Alterman RL. Deep brain stimulation for intractable psy-
chiatric disorders. Annu Rev Med. 2012;63:511-524.
42. Russell EJ, et al. Risk of obsessive-compulsive disorder in pregnant and
postpartum women. J Clin Psychiatry. 2013;74(4):377-385.
43. Forray A, Focseneanu M, Pittman B, McDougle CJ, Epperson CN. Onset
and exacerbation of obsessive-compulsive disorder in pregnancy and
the postpartum period. J Clin Psychiatry. 2010;71(8):1061-1068.
4 4. Namouz-Haddad S, Nulman I. Safety of treatment of obsessive compul-
sive disorder in pregnancy and puerperium. Can Fam Physician. 2014;
60(2):133-136.
45. Practice parameter for the assessment and treatment of children and
adolescents with obsessive-compulsive disorder. J Am Acad Child Ado-
lesc Psychiatry. 2012;51(1):98-113.
4 6. Piacentini J, Bergman RL, Chang S, et al. Controlled comparison of fam-
ily cognitive behavioral therapy and psychoeducation/relaxation train-
ing for child obsessive-compulsive disorder. J Am Acad Child Adolesc
Psychiatry. 2011;50(11):1149-1161.
47. Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior ther-
apy, sertraline, and their combination for children and adolescents with
obsessive-compulsive disorder. JAMA. 2004;292(16):1969-1976.
4 8. Singer HS, Gilbert DL, Wolf DS, Mink JW, Kurlan R. Moving from PANDAS
to CANS [published correction appears in J Pediatr. 2012;160(5):888].
J Pediatr. 2012;160(5):725-731.
49. Fenske JN, Schwenk TL. Obsessive-compulsive disorder: diagnosis and
management. Am Fam Physician. 2009;80(3):239-245.
American Family Physician 903